Form

DentalandVisionIns.com
Request a Premium Payment via Credit Card. Please read the information below.
This is a TWO step process.

We will process your request for a credit card payment and send you an invoice via email to make your payment directly on the PayPal website. This email invoice will expire in 5 business days.

Once you receive the email invoice and complete the payment using the link on the email, we will post the premium payment to your account.

You do not have to be a PayPal member to make a payment.

To cover the cost of processing the credit card payment we will add a 3.5% fee (minimum fee is $2.00) to your premium amount due. The fee will be shown as 'shipping'.

Your premium payment is due on the date shown on your invoice. You have a 30 day grace period before your account becomes in jeopardy of being cancelled. We will send you an additional notice or "Reinstatement Offer" prior to canceling your coverage.
Your E-mail *
This is used to send you an invoice through Paypal.
Phone Number *

- Area Code Phone Number
Client ID, Payment to be posted to this account. *
Example: 9874-1234, 82000-3, 123456-0
Name on Account *
Premium Amount Due.
Leave this blank if you want us to calculate the amount due.
This pays the premium through the month of: *
Please enter the month you wish to be paid through.
Please give us any additional information you feel is necessary in processing this request.
By clicking on the Submit button below, you are indicating your agreement to have this premium payment invoiced with the additional fee of 3.5% (minimum fee is $2.00).
This fee is shown as 'shipping' on your receipt.

We will send you an email invoice to make your payment.

This is a one time payment. We do not set up recurring credit card payments.
Should be Empty:

Request a Premium Payment via Credit Card. Please read the information below.